1932522273 NPI number — LIFETIME VISION AND CONTACT LENS CENTER

Table of content: CANDICE M. KEENE DPT, ATC (NPI 1912226119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932522273 NPI number — LIFETIME VISION AND CONTACT LENS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME VISION AND CONTACT LENS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932522273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 MEMORIAL DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
CRYSTAL LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014-6278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-459-7110
Provider Business Mailing Address Fax Number:
815-459-7138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MEMORIAL DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-6278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-459-7110
Provider Business Practice Location Address Fax Number:
815-459-7138
Provider Enumeration Date:
01/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SPRAGUE
Authorized Official First Name:
LAMONT
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
OPTOMETRIST/OWNER
Authorized Official Telephone Number:
815-459-7110

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046010544 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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